| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(b) | At 10:31AM, mouse droppings were on a shelf in a closet in the basement of the home. [Repeat Violation, 3/29/2023] | There may not be evidence of infestation of insects or rodents in the home. | Orkin Pest Control came out to the residence to provide treatment to observe and exterminate mice. Mouse traps were put in place where the mouse drop was found on 7/27/23.
A mandatory meeting was held on August 2, 2023, discussing how DSP staff will be observing for mice, keeping areas clean, and garbage removal. |
08/28/2023
| Implemented |
| 6400.77(c) | There is not a first aid manual in the home's first aid kit. | A first aid manual shall be kept with the first aid kit. | A printed first aid manual was put in the first aid kit immediately after findings. |
08/28/2023
| Implemented |
| 6400.81(k)(6) | There is not a mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | A stick-on mirror was put in place so that the Individual #1 is unable to remove it. The self-adhesive mirror is safe and will not break; it is glued to smooth part of the consumer's wall. |
08/28/2023
| Implemented |
| 6400.105 | At 10:33AM, there was an 3/4 inch thick of accumulation of lint in the dryer lint trap. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| A mandatory meeting was held on August 2, 2023 concerning the removal and disposal of lint form the lint trap. A laminated sign was put on all dryers reminding to remove lint after every use. DSP staff were trained by the Residential Supervisor on the new visible lint removal sign located within the laundry room. DSP staff were trained on the safety precautions of the lint being removed from the dryer after each use. |
08/28/2023
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Clobazam 10MG tablets with instructions to increase the dosage with the following pattern, "take 1/2 tablet by mouth twice daily for 1 week for seizures," then "take 1/2 tablet by mouth in the morning and 1 tablet at bedtime for 7 days for seizures." The increased medication dosage was scheduled to start on 7/27/2023 and end on 8/2/2023 per physician's orders. It is initialed as administered at 8:00and 8:00PM daily from 8/22/2023 through 8/26/2023. [Repeat Violation, 3/29/2023] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | On 07/28/2023 The physician's office was contacted for clarification on the titration instructions the pharmacy was contacted, and a new MAR was received with corrected instructions. At a mandatory meeting on August 2, 2023, the staff was trained by the Residential Supervisor to review the medication administration documentation with the staff. |
08/28/2023
| Implemented |
| 6400.166(a)(15) | Individual #1 is prescribed Polyethylene Glycol with instructions to, "Mix 1/2 capful (titrated down to 1/8 capful if loose stools) in flavored water and drink by mouth once daily for constipation." Individual #1's July 2023 Medication Administration Record reads, "Scoop powder mix and dissolve 1/2 cap in 6 ounces of flavored water for constipation." The Medication Administration Record does not include the special precaution to titrate down if loose stools. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | A mandatory meeting was held on August 2, 2023. DSP staff were trained by the Residential Supervisor to properly complete and utilize the Bristol Stool Chart to record drug effectiveness and how to monitor dosage administered. Staff are trained on tracking Individual #1's bowel movements and what to do if there are causes for concern. |
08/28/2023
| Implemented |